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Intraoperative Predictors of Laparoscopic Cholecystectomy
criteria were preoperatively proven GB malignancy, refractory characteristic (ROC) curve was plotted to estimate the cutoff value
coagulopathy pulmonary disease, end-stage liver disease, and any for the scoring system.
corticobasal degeneration pathology.
Sampling results
We decided to include all the eligible cases fulfilling the study We enrolled 200 patients in our study, out of which 85 patients had
criteria by undergoing LC under a single surgeon unit for the difficult LC. The majority of the participants were females (n = 148),
study. A single surgeon unit criterion was selected to prevent while the mean age of all the participants was 40.95 ± 11.08 years.
intraobserver bias. Surgeons with experience of more than 50 Most of the patients were presented with chronic cholecystitis.
LCs did all the surgeries in this study. For the selection of cases, The detail of study participants has been given in the previous
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consecutive sampling was done. During the study period, a total publication. Association of various predictors was analyzed by
of 200 patients undergoing LC who met the study criteria were binary logistic regression analysis, and their adjusted odds ratios
selected for the study. were measured as shown in Table 1.
The proposed score for predicting difficult cholecystectomy
Definitions during intraoperative surgery is given in Table 2. As seen in the
Difficult cholecystectomy was defined in this study as ROC curve (Figs 1 and 2), a score of 6 was selected as the best cutoff
point compromise between maximum sensitivity and specificity.
• A total duration of more than 70 minutes for LC from the A cutoff point at 6 has a sensitivity of 87.1% and a specificity of 88.7%
insertion of Veress needle till the extraction of GB (Fig. 2). We also performed internal consistency of the proposed
• Requiring more than 20 minutes to dissect the Calot’s triangle scores by using Cronbach’s coefficient alpha, which was 0.71, which
• Requiring more than 20 minutes to dissect the GB from the liver is considered adequate for an attitudinal scale. 10
bed
• Conversion to open cholecystectomy
dIscussIon
Study Procedure The present study was done to design a scoring system predicting
After the approval by Institutional Ethics and Research Advisory difficult outcomes during intraoperative LC. This scoring system
Committee, JN Medical College, Aligarh, enrollment was started. would help in identifying high-risk patients who may have difficulty
The patients fulfilling the selection criteria were explained about during LC and thus in preventing complications beforehand. The
the study, and those who gave informed consent were selected. present study assessed various operative factors for LC and found
The selected patients who were fit for the laparoscopic surgery GB condition; GB adhesion, intra-abdominal adhesion, presence
after preanesthetic checkup were planned for the surgery. During of pericholecystic fluid, Calot’s triangle status, and cystic duct
the LC, the following things were taken into notice: and vessels abnormality were predicting difficult LC. On basis of
these variables, we devise a grading system to evaluate difficulty
• Abdominal wall scar mark during LC.
• Creation of the pneumoperitoneum Our study was supported by various studies that also found
• GB condition that significant factors like intra-abdominal adhesion, inflamed GB,
• Separation of all adhesions frozen Calot’s triangle, as well as abnormal anatomy of vessels and
• Liver condition cystic duct were predicting difficult LC, although not with others
• Skeletonization, ligation, and division of cystic artery and cystic who also observed obesity and previous abdominal scar mark as
duct predictors. 3,6,11–15 Lal et al. suggest that a difficult LC is one which
• Excision of GB from the GB fossa of the liver bed takes more than 90 minutes for completion and tearing the GB,
• Extraction of GB. takes more than 20 minutes in dissecting the GB adhesions, or takes
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Overlapping of these intraoperative difficulties was recorded. more than 20 minutes in dissecting the Calot’s triangle. While the
The total duration of the surgery from the insertion of the Veress time taken for Calot’s triangle dissection varies based on surgical
needle into the closure of the port site as well as the time for Calot’s skills and the level of experience, it is usually longer in patients
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triangle dissection was noted by stopwatch. with difficult access, inflammation, and adhesions. In this study,
we considered that difficult LC takes 70 minutes in completion
Data Management and Statistics and 20 minutes each in the dissection of GB from the liver bed and
The data were entered and analyzed in Statistical Package for Calot’s triangle.
Social Sciences (SPSS) version 20. Statistical significance was There is limited success in formulating an intraoperative scoring
tested first by binary logistic regression analysis, and then, system in LC. One developed by Vivek et al. is complex having 22
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multiple logistic regression analysis was calculated to find out parameters including four intraoperative LCs, thus not easy to use.
adjusted odds ratio. The odds ratios express how many times a Their scoring system had a maximum score of 44, and a score of
preoperative variable is likely to be found in the difficulty group 9 was predicted as difficult LC with sensitivity and specificity of
as compared to the easy group. As adjusted odds ratio had a 85 and 97.8%, respectively. Our scoring system has a sensitivity of
wide range, to avoid the same for the proposed score, adjusted 87.1% and a specificity of 88.7%, with an area under the ROC curve
odds ratios were divided by ten and rounded off to the nearest as 0.953. Another scale proposed by Randhawa et al. was validated
numerical. The proposed scoring system was tested on the original in Indian settings by Gupta et al., which graded difficult LC from
intraoperative data of the study subjects. The individual score of 0 (easy) to 15 (very difficult). 15,16 Although their scale is easier, but
each patient was calculated. The sensitivity and specificity of the only a few operative features like thickened (≥4 mm) GB wall and
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proposed scoring system were computed, and receiver operating impacted stone are given importance. Sugrue et al. conducted

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